What are the recommended treatment guidelines for newly diagnosed hypertension?

Treatment Guidelines for Newly Diagnosed Hypertension

According to the 2020 International Society of Hypertension (ISH) guidelines, treatment for newly diagnosed hypertension should be based on blood pressure levels, cardiovascular risk factors, and comorbidities, with immediate drug treatment recommended for those with BP ≥160/100 mmHg or high-risk patients with BP 140-159/90-99 mmHg. 1

Diagnosis and Assessment

Blood Pressure Measurement

• Use validated automated upper arm cuff device with appropriate cuff size
• At first visit, measure BP in both arms; use the arm with higher BP if consistent difference
• For office BP measurement, use the average of readings after patient is seated quietly for 5 minutes 1
• Confirm elevated office readings (≥130/85 mmHg) with home or ambulatory BP monitoring:
  • Hypertension diagnosis: Home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg 1

Risk Assessment

• Evaluate for:
  • Cardiovascular disease (CVD)
  • Chronic kidney disease (CKD)
  • Diabetes
  • Target organ damage
  • Age (especially 50-80 years) 1

Treatment Algorithm

For BP 140-159/90-99 mmHg (Grade 1 Hypertension):

1. Start lifestyle interventions immediately
2. Start drug treatment:
   • Immediately in high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years)
   • After 3-6 months of lifestyle intervention in low-moderate risk patients if BP remains elevated 1

For BP ≥160/100 mmHg (Grade 2 Hypertension):

• Start both lifestyle interventions and drug treatment immediately 1

Pharmacological Treatment

First-Line Medications

• Non-Black Patients:

  1. Start with low dose ACE inhibitor (ACEI) or ARB
  2. Increase to full dose
  3. Add thiazide/thiazide-like diuretic
  4. Add spironolactone or alternative (amiloride, doxazosin, eplerenone, clonidine, beta-blocker) 1

• Black Patients:

  1. Start with low dose ARB + dihydropyridine calcium channel blocker (DHP-CCB) or DHP-CCB + thiazide/thiazide-like diuretic
  2. Increase to full dose
  3. Add diuretic or ACEI/ARB
  4. Add spironolactone or alternative 1

Special Considerations

• Consider monotherapy in low-risk grade 1 hypertension and in patients aged >80 years or frail
• Use once-daily dosing and single-pill combinations when possible 1
• For patients with CKD, ACE inhibitors or ARBs are preferred first-line therapy 2

Lifestyle Modifications

Implement the following lifestyle changes for all hypertensive patients:

1. Weight management: 5-20 mmHg reduction per 10 kg lost 2
2. DASH diet: Rich in fruits, vegetables, whole grains, and low-fat dairy (8-14 mmHg reduction) 2
3. Sodium restriction: <2000 mg/day (2-8 mmHg reduction) 2
4. Physical activity: 150 minutes/week of moderate-intensity activity (4-9 mmHg reduction) 2
5. Alcohol moderation: ≤1 drink/day for women, ≤2 drinks/day for men (2-4 mmHg reduction) 2

Treatment Targets and Monitoring

• BP target: <130/80 mmHg for most adults 2
• For elderly: Individualize based on frailty; target reduction of at least 20/10 mmHg; ideally to <140/90 mmHg 1
• Monitoring schedule:
  • Achieve target BP within 3 months 1
  • Follow-up within 1 month for BP 130-139/80-89 mmHg
  • Follow-up within 2-4 weeks for BP 140-159/90-99 mmHg
  • Follow-up within 1-2 weeks for BP ≥160/100 mmHg 2
  • Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of starting ACEIs, ARBs, or diuretics 2

Common Pitfalls and Caveats

1. Medication selection: Beta-blockers are less effective for stroke prevention and not recommended as first-line unless specific indications exist (e.g., coronary artery disease) 2

2. Combination therapy: Never combine ACE inhibitors with ARBs as this increases risk of hyperkalemia and acute kidney injury without additional benefit 2

3. Racial differences: Thiazide diuretics and CCBs are more effective as initial therapy in Black patients 2

4. Elderly patients: Start medications at lower doses and titrate more slowly, with careful monitoring for orthostatic hypotension 2

5. Medication adherence: Simplify regimens with once-daily dosing and single-pill combinations when possible 1

If BP remains uncontrolled despite optimal therapy, refer to a specialist with hypertension expertise 1.